Cognitive Problems in Veterans With Heart Failure

Heart failure (HF) is a costly, chronic, and complex condition that impacts veterans'
quality of life, morbidity, and mortality. In the VA population up to 20% of patients are
readmitted for HF within 30 days, and the CHF QUERI's 2008 Strategic Plan ranks lowering
readmission rates as the highest in priority of clinical issues to be addressed.

Non-adherence to prescribed medication and self-care regimens in patients with heart failure
is well known to lead to increased morbidity, including readmissions. Despite multiple
modalities of patient education there remains a failure on the part of many patients in our
outpatient HF clinic to adhere to even a carefully individualized plan of care. We have
termed this care deficit the "patient adherence gap".

In the non-veteran population, HF patients are known to have an increased prevalence of
cognitive impairment (CI), however, no existing study has determined the extent and type of
CI in veterans with HF. There are also no published data sufficiently evaluating the link
between CI and adherence or the link between CI and readmissions in heart failure
populations.

To address this need, we have designed a descriptive cross-sectional study as a
pre-implementation effort. We hypothesize that the presence of CI negatively impacts
adherence and contributes to the patient adherence gap, which in turn results in increased
readmissions for HF. Goals of this pilot study are to: (1) evaluate the association of CI
with adherence (measured by compliance with medications); (2) determine the prevalence of CI
in veterans with all-cause HF in an outpatient setting; (3) quantitatively describe the
extent of CI in this population; (4) qualitatively describe neuropsychological domains
affected by CI.

To accomplish these goals, all consenting eligible outpatients in our VA HF clinic will
undergo a simple screening test for CI (SLUMS). We will also interview the patients to
collect demographic and clinical data, and to rate them on the geriatric depression scale.
If the subjects screen positive for CI, they will undergo further evaluation by a battery of
neuropsychological tests. Adherence will be evaluated by a direct 30 day pill count, a
brief questionnaire measuring intentional nonadherence, and a review of pharmacy refill
records. We will follow patients after the 12-month study period to collect data on hospital
readmissions.

Results from our study will test the feasibility and utility of screening for CI in
outpatient HF population, using simple and cost-effective tools. It will also provide
valuable data to support our future intervention trial assessing the impact of CI
intervention on outcomes, such as improved adherence and reduced admissions.